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Revised EP for Licensed Practitioner Evaluations Will Improve Quality, Save Time and Reduce Costs


Neck down view of four doctors crossing their arms.
By Diane Meldi, MBA, CPCS, CPMSM, FMSP, and Molly Ford, MPP

The Joint Commission recently extended the timeframe for licensed practitioner evaluations from two years to three years to align with standard practice and to help streamline and enhance quality-assessment processes.

Revised Elements of Performance (EP) now state that an organization can grant initial, renewed or revised privileges for “three years or for the period required by law and regulation if shorter.” The revised EP is applicable to ambulatory care and office-based surgery, behavioral health care and human services, hospitals including critical access hospitals, and nursing care services under various standards, including Human Resources (HR), Human Resources Management (HRM) and Medical Staff (MS).

These revised EPs will benefit both healthcare organizations, for which it will help to improve quality and reduce costs, as well as medical services professionals (MSPs) who provide medical staff and credentialing services. 

Revised EP will help MSPs focus on comprehensive quality assessment
MSPs are experts in quality analysis and are essential to ensuring patient safety across all types of healthcare organizations. Ensuring safety requires MSPs to use their training and skill sets to initially credential, as well as continuously assess, practitioners. A three-year evaluation schedule will give MSPs more time to comprehensively assess practitioners with clinical privileges via ongoing monitoring. Because reappointment processes and ongoing monitoring require MSPs to perform similar analyses, a three-year EP schedule will reduce duplications and enable MSPs to assess practitioners more efficiently and comprehensively. 

Physician leaders will also benefit from this revision, as it will enable them to focus on elements of quality and clinical privileges thoroughly every three years instead of two.

Reappointment is a lengthy process that can often take six months to complete. The process requires the practitioner to submit an application to the medical staff office and MSPs to review the practitioner’s clinical privileges, verify state licenses and board certifications, and collect and evaluate quality data and peer reviews. The cost of the application process and approval is estimated to be $600 to $800 per applicant. Therefore, reviewing reappointment applications every three years instead of every two years also will save money.

Stakeholder input resulted in this change
The National Association Medical Staff Services (NAMSS), the membership organization for over 6,000 MSPs, applauds The Joint Commission for extending the reappointment timeframe to three years. In 2021, NAMSS hosted a stakeholder roundtable for organizations including the American Hospital Association, American Medical Association and its Organized Medical Staff Section, Centers for Medicare and Medicaid Services, and The Joint Commission to discuss the benefits of moving to a three-year reappointment schedule. NAMSS also released a position statement in 2021 supporting three-year reappointment and enhanced continuous monitoring processes.  

NAMSS is proud to call The Joint Commission a partner in streamlining and enhancing quality-assessment that encourages growth while helping to ensure patient safety.

Review your state’s reappointment requirement
Despite The Joint Commission’s revised EPs, some states still require a two-year recredentialing process due to existing statutes. MSPs should review their state’s reappointment requirements to ensure compliance. NAMSS in the meantime will work with its strategic partners to help these states update their laws to align with The Joint Commission revised policy. For example, Mercy Health is advocating in the four states in which it operates (Oklahoma, Kansas, Arkansas, and Missouri) to change the two-year reappointment requirement to three. 

Healthcare organizations in states not limited by a two-year reappointment requirement can move to a three-year reappointment process. MSP and medical staff leaders should create an action plan and timeline to implement a three-year reappointment schedule. Medical staff bylaws, policies, procedures, processes, and other documents may need to be revised, reviewed and improved before you can begin this new three-year process. 

NAMSS will continue to provide the education and resources MSPs need to be at their best, and that's something that we all work toward. Look for more NAMSS resources soon to help navigate this change at the organizational level. MSPs are the gatekeepers of patient safety. Their role is critical to ensuring that patients are safe and that those who are providing care have the competencies and the privileges to do so. 

Diane Meldi has more than 25 years of experience as a medical services professional. Employed by Mercy Health in Springfield, Missouri, as a senior consultant, she serves on the NAMSS board as a government relations and stakeholders liaison. Molly Ford oversees advocacy, policy and government relations for the National Association Medical Staff Services (NAMSS), which works to enhance the professional development and recognition of the medical services profession through education and advocacy.